A Low Blow.

That crisp feeling of morning freshness was slowly beginning to fade. My state of calm was beginning to substitute itself with discomfort. i could feel this rapid sensation slowly washing over my entire body.

I glanced at my pump, which told me that I had point six of a unit of insulin on board. I reached into my grey pencil case, and popped two pink raspberry glucose tablets into my mouth. I thought about the temporary basal rate that I’d had running up until an hour ago to correct an early morning blood sugar of 15mmol, and begrudgingly shoved a third tab into my mouth. 

My legs were feeling unusually stuffy, even if they were concealed under trackpants on a warm November day. Beads of sweat were building underneath my arms, and rapidly extending across my upper body. Within minutes I could feel my shirt sticking to my skin, and my pants against my thighs.

A wave of exhaustion suddenly washed over me. My whole body felt…heavy. Every movement, every step I took was an effort. I was struggling to focus on titles in the box of games I was holding, frantically wanting to check them off on the invoice in front of me. The invoice that would be my ticket out of the room.

How long had it been? Five, possibly ten minutes? Nah, couldn’t be any more than five.

I walked back over to my pencil case, and popped another two glucose tabs into my mouth, desperate for this wave of discomfort to pass. I grabbed the invoice and walked off to the office, ignoring a shrill call for my name that was heading in the opposite direction of me.

I collapsed into the chair, and leant forward onto the desk.

I was limp. I didn’t want to work my way through this, like I so often do. I just wanted to sit there, and wait for the exhaustion and the sweats to pass.

The shrill voice finally found me, and the words I knew I’d have to say escaped my mouth before she even had a chance to ask me for help.

“I just need a minute.”

“I’ll be back out there soon.”

I explained that my blood sugar was low, and that I just wanted to sit there and wait for it to pass. I was offered tic tacs and an orange, which I politely refused, insisting that I had already treated and just needed to wait it out. Said person politely went and grabbed me a glass of water, which was exactly what I needed in that moment.

Five minutes passed.

I got out of my chair and walked down to the kitchen to refill my glass of water. I walked into the mens, washed my hands and tamed my sweat with some anti-perspirant.

I went back to work, wondering if this new acquaintance to my diabetes would feel the need to tread on eggshells around me.

I hope not.

Foggy

I stirred in the darkness. I felt sticky. I could feel the dampness building around my neck and my thighs. I could feel heat emitting from the pillow where my stuffy head had been resting. Leaving the quilt on my bed last night was probably a bad idea.

I felt shaky. I could feel my entire upper body vibrating, as I lay there under the covers. Could I be?

But I didn’t want to open my eyes. I didn’t want move a muscle. I couldn’t gauge exactly why this was, but my brain couldn’t overpower my body that morning as I lay paralysed in bed.

BLEH BLEH BLEH BLEH…

No sooner than I had closed my eyes again, my alarm began to sound. It startled me. I couldn’t believe it was morning. I couldn’t believe I hadn’t registered the time on my clock radio when i stirred only moments ago.

I fumbled hurriedly for my phone, desperate to silence the blaring alarm. I felt disoriented. I felt weak. I switched on my bedside lamp, and reached for my meter.

2.6. My blood sugar was sitting at lowly 2.6.

I frantically got out of bed, pulled my retainers out of my mouth and fumbled around on my dresser for the ancient yellow-rimmed coffee cup where I could dunk them into.

I could still feel those shakes as I walked into the kitchen, like someone had frightened me. I poured milk into my coffee cup, and placed it into the microwave to heat up. Once the 45 seconds were up, I placed it under the coffee machine, watching the sweet brown liquid drip slowly into my cup.

I felt thirsty. I washed that coffee down my throat in big gulps, as a way to quench my thirst. I reached for biscuits. One of Nonna’s amaretti topped with a glace cherry, followed by a choc chunk cookie.

I wondered how long I had been low. I knew I had gone to bed sitting on a 4.9. I had eaten 3 skittles as well, which should have brought my blood sugar closer to 6. I hoped I hadn’t been sitting low for too much of the night.

As the shakes subsided, the brain fog began to set in.

As I went about my morning moving pallets and pushing trolleys, I could feel aches in my very weak arms and legs.

Those aches were a lasting reminder of that hypo.

Those aches left me feeling riddled with guilt.

Some added science from my friend Matt: Apparently your muscles are repairing overnight, and if there isn’t enough sugar for them to slurp on…ouch is incurred.

How I Manage My Blood Sugar During Exercise

I’ve learned a fair bit about physical activity, and how to manage my diabetes around it in the past year. I guess having my job and my income depend on it, is a big motivation.

I am physically active at work every day, which means that I am more sensitive to insulin and more prone to going low through the day. Combine this with trying to offset dawn phenomenon when I wake up each morning, and you’re left with one very tricky equation.

One positive of combining work and exercise, is that every day is Groundhog Day. There is no shortage of opportunities to experiment. And when something does go wrong, I get to repeat it the following day in almost identical conditions. Not to mention that I don’t need to feel guilty about telling my doctor that I don’t go to the gym!

The negative is that at times, diabetes has felt very gruelling to manage while I am at work. The motivation to basal test, or to conduct experiments, isn’t always there. There have been days where I’ve literally been juggling highs and lows with insulin and food, respectively. There have been weeks where I felt like I haven’t gotten anywhere, and it’s often hard to pick myself back up and carry on.

Your diabetes, and the kind of physical activity that you undertake, will likely be different to mine. However, here are a few of the strategies that have worked for me while I have been physically active in recent months.

I would class my level of activity as mild – being on my feet, lots of walking around, some climbing up and down ladders and lifting. There are some days where it is more intense than usual – particularly if we are busy. But I find that most days, my level of activity is identical.

I find that for this mild level of physical activity, I need 30% less basal insulin compared to when I am vegging out at home. The 30% reduction in basal insulin needs a lead time of around half an hour before I start work. Most would suggest an hour’s lead time, however I don’t feel that my level of activity is at full speed until half an hour into my work day. I.e. I’m spending too much time chatting to people in the morning!

Mealtime boluses are still a work in progress. I’m currently sitting on 1 unit for every 8 grams of carbohydrate. At breakfast, my full insulin dose does its job, as I’m not on my feet for another hour and there’s probably some dawn phenomenon in play. I’ve tried reducing my insulin dose for meals during my work day with mixed results. At morning coffee time, I’m dosing insulin or snacking while I’m on my feet. Whereas at lunch time, I’m dosing insulin at the start of my break and not going back out to work for another hour. I’m working with a 30% bolus reduction with morning tea, and 15% with lunch.

I’m probably about two thirds of the way there. My overnight, and morning BGLs are looking fantastic. I just need to focus on getting some more green numbers into the afternoons, so that I’m not going home and snacking or eating dinner on higher numbers. It’s been an ongoing issue.

Work has been a gruelling journey, but I have finally began seeing results in recent months. Putting the hard work into fine tuning my basal rates and mealtime boluses has been invaluable towards a productive day, free from the stress of highs and lows.

I’m not so terrified of going to work without wearing a Libre sensor anymore, and I can comfortably go for two or three hours without needing to check my blood sugar. When I uploaded my meter data to Diasend on the weekend, I realised that I had only had three lows in the last fortnight. Freaking awesome. I finally feel a level of confidence in what I’m doing. 

Another piece of advice that I never gave myself: give yourself a break. When I was on injections I would often come home with exhausting lows, crash on the couch and eat my way out of it with junk food. I failed. Constantly. The task of fine tuning insulin felt overwhelming, and the motivation was never there. After my pump start, I was under the illusion that I’d have everything down pat in a number of weeks. In hindsight that was such an unrealistic goal. Give yourself some room to breathe. Maybe basal test every second day. Or have a few days off from your experiments if they’re feeling overwhelming. Set small goals.

As with any element of managing diabetes, it takes a lot of time and patience. You won’t necessarily get it right the first time. Or even the tenth. Goal posts are always moving, because diabetes is always changing. You’re always learning, and putting two and two together.

But with time, you pick up these valuable little skills that will make fine tuning your next diabetes scenario a little easier.

Multiple Daily Injections, a Second Time Round


I definitely felt hesitant about going back to Multiple Daily Injections when I was contemplating a pump break.

I didn’t really have too many fond memories of managing diabetes prior to insulin pumping. Lantus was very uneven and inconsistent the last time I used it. I felt I could never get the dose quite right. I remember lots of carb guesstimates, and the wildly fluctuating levels that followed.

But at the same time I knew that I was armed with a lot more knowledge, and motivation compared to when I last did injections. I was actually curious as to whether I could apply these newfound skills into Multiple Daily Injections a second time round.

I gave 9 units of Lantus at around 9pm on the first night of my pump break, which was the sum of the 24 hour basal profile on my pump. I was pretty pleased to see that it did keep me fairly stable when I woke up the next morning.


I was definitely contemplating splitting my Lantus dose, but I wasn’t sure how best to go about it. The general consensus in forums seemed to be that Lantus lasted around 18 hours at best. After running high during the first two afternoons, I decided to experiment with a smaller second dose at 1pm to cover the final third of my day. 3 units seemed to be enough to cover, without sending me low overnight.

After months of diligent carb counting, I knew I definitely wouldn’t be able to survive without a bolus calculator. Although there were plenty of flashy diabetes apps to choose from in the App Store, many of them lacked a bolus calculator. I eventually found RapidCalc for $12.99. Although it didn’t have the flashiest interface, it fitted my needs nicely. I was able to set up my insulin to carb ratios, correction factors, insulin usage profile, and reminders for my Lantus doses.


This break definitely reinforced that to me that you tend to use less insulin on the pump. On the pump, I was using a carb ratio of 1:10g and a correction factor of 1:2.6mmol. On injections, I needed a ratio of 1:6g and a correction factor of 1:1.6mmol. Being off by even half a unit of insulin had a big impact on my blood sugar levels after meals.

What I loved most about injections was the simplicity of it all. There was instant relief from the lows, and far less thinking about where my blood sugar was heading. Small activities around the house had minimal effect on my blood sugar levels. I witnessed steady trend arrows on my Libre during afternoon walks, rather than downward ones. Using Lantus for my basal, rather than rapid acting insulin on the pump, made a BIG difference here. The only time I had to think about lows was when I had mealtime insulin on board.

Gotta say, it was also just awesome to sprawl out on the couch or in bed and not feel that chunk there in my pocket. And I loved having a little less weight in my pockets every time I left the house.

Overall, my blood sugar levels were just as good on injections as they were when I was pumping.

But shots were definitely a LOT of work. Although I carried my pen around with me in my pocket everywhere, I don’t shoot up in front of others. So I really had to make a point of finding a quiet corner to do so when I wanted to eat or correct a high blood sugar level. Speaking of, morning blood sugars were a LOT harder to manage. I didnt have the flexibility of increasing my basal insulin to cover the morning rise after I woke up. I often found myself giving at least 3 corrections after breakfast to bring me back into range. If I had stuck with injections for longer, I would definitely basal test with a few extra units of rapid acting insulin to cover the morning rise.

My pump break definitely reminded of something that Ginger at Diabetes Daily wrote recently. She says that neither pens or pumps were perfect, and that we were choosing between the flaws that bothered us the least. I couldn’t agree more.

For me personally, an insulin pump is a LOT more work than injections. Keeping on top of site changes, dying batteries and insulin cartridges, and having to be on my game in setting basal rates around my activity. It’s more careful thinking about what you’re doing. Not to mention the extra chunk in my pockets pulling my shorts down!

But a pump also offers me more convenience when I’m on the go, more precision in my basal rates and greater flexibility with insulin dosing to cover different kinds of meals.

For the time being, those benefits outweigh the flaws when managing my diabetes.